The call to radically change the face of TB in the new Global TB strategy
Radical change in the approach to TB prevention, diagnosis and case management is needed if new global targets are to be achieved, participants in a 23 June consultation hosted by the Stop TB Partnership said.
The event, one of several in-person discussions being held alongside Global Fund partnership forums, is part of a new consultative approach being promoted by the Stop TB partnership to develop its 2016-2020 strategy (see article here).
A draft document in circulation during the day-long event attended by 35 participants outlines a strong and detailed approach to “bending the curve” against TB, reflecting the determination to dramatically change the annual decline of new TB cases, which has been stagnating at 1.5%.
This disappointing trend continues despite concerted efforts and good economic growth in many of the countries with high disease burdens, demonstrating the need for new approaches to diagnosis if progress is to be made towards the goal of ending the TB epidemic by 2035.
The strategy centers on ambitious 90-(90)-90 targets:
Find and diagnosis at least 90% of people infected with TB and place them on appropriate therapy
Make a special effort to reach at least 90% of the key populations groups: the most vulnerable, underserved, at risk populations
Reach at least 90% treatment success through affordable treatment services, promoting adherence and social support
The new approach aims to inspire communities, governments and global partners, drawing on some of the successes learned from comparable HIV or vaccination campaigns, invigorating the fight against the world’s oldest human disease.
Differentiation at country level
The draft strategy makes a first attempt at defining – and responding – to the different country contexts for the highest-burden countries. Epidemiological factors, health system constraints, and TB socio-economic factors are used to define nine country categories. Due to the size and circumstances for India and China, two of the highest proportional burden TB countries, they are given their own categories. However, despite the nuanced categories, there are still countries, such as those in the Pacific, that do not fit neatly.
For Papua New Guinea, which is facing a challenging emerging drug-resistant epidemic, this could be particularly problematic when trying to access future funding for TB. If countries such as PNG and Fiji do not fit within the country categories of the Global Stop TB Strategy, there are concerns about what this will mean for future donor funding for these programs.
The draft strategy also has a a strong focus on reaching key populations.
People who have increased exposure to TB bacilli due to where they live or work
People living in urban slums, contacts of TB patients, or prisoners;
People who have limited access to quality TB services
People from tribal populations, migrant workers, people who are homeless, women in some rural areas, children, refugees, hard- to-reach areas, fishermen, illegal miners.
People at increased risk of TB because of biological or behavioural factors that compromise immune function
People living with HIV, diabetes, or silicosis; people undergoing immunosuppressive therapy, people who are undernourished, smokers, alcohol abusers, or people who use drugs.
Key population categorization is not a one-size-fits-all model for countries. The participants strongly recommended that the key population group definitions should not be considered an exhaustive list, but rather an indication of priority groups to be considered at country level. There were very strong recommendations from the group to ensure that adolescents and students were also included as key population groups for TB interventions.
The preliminary costing of the plan was presented based on two scenarios. If the scale-up to reach the 90-(90)-90 targets is completed by 2020, global costs would top out at 9.5 billion USD per annum up to 2020, but would reduce thereafter. A more realistic plan of scale-up by 2025, will require $42 billion over the life of the strategy, and a higher financial need after 2020 than the first scenario. Dr Lucica Ditiu, the executive secretary of the Stop TB Partnership, highlighted the funding issues, noting that “by 2017 there would be a $6 billion funding gap”.
Figure 1: Cost of the Global Plan (Source: http://stoptbplan2020.org/wp-content/uploads/2015/06/Global-Plan-to-Stop-TB-2016-2020_Draft-9-June-2015_.pdf)
Another risk to TB funding comes from the fact that it relies heavily on a single donor: the Global Fund, which finances 72% of TB programming worldwide. Of the remaining 28%, 83% comes from domestic resources. With 50% of the world’s TB burden in the BRICS (Brazil, Russia, India, China, South Africa) countries, it is clear that more money needs to be found locally, even to maintain current diagnosis and treatment levels.
Two clear themes emerged from the Bangkok consultation: how to highlight the paradigm shifts in TB control and how to expand the role of the private sector in carrying out that shift. Changing attitudes and action begins with a change in the narrative – moving away from TB control to TB eradication and shifting the focus from saving lives to stopping transmission.
Meanwhile, more attention should be paid to bolstering private sector engagement in TB, through fostering innovation and incentives. Participants highlighted that the days of top-down government models with limited private sector engagement were over; the time is nigh for a collaborative model. This will require greater integration of TB with other health programs in private service delivery. Success will depend on an environment that is more accepting of revenue generation in social business models, such as the one being used in Pakistan where increased GeneXpert testing in the private sector is combined with lung health and diabetes care..
Future consultative processes would do well to adopt some of the elements of the Stop TB strategy development. In providing the draft strategy in advance, the Secretariat ensured that participants were well-informed and thus able to fully engage in discussions. However, the inclusiveness only went so far. Despite a diverse mix of private sector, civil society, parliamentarians, donors, TB patient and advocacy groups, that there was no representation from the any of the Pacific countries in the Western Pacific Region. The consequence is countries like PNG are at risk of facing rapidly developing drug-resistance TB epidemics that could threaten gains elsewhere in the region without adequate levels of support because the simply do not fit the definitions outlined in Global Strategies.
The Stop TB Partnership has made the draft strategy available online for comment and consultation until 10 August. Regional consultations are also planned for Istanbul in late July and Buenos Aires in September. The resulting Global Plan to Stop TB 2016-2020 will be launched at the 46th World Union on Lung Health in Cape Town in December 2015.